Add a New Provider - Prime Healthcare

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Add a New Provider or Term an Existing Provider

Add a New Provider or Term an Existing Provider Local

What do you want to do?

Add a New Provider

Term a Provider

Do you need to term a single Specialist or multiple?

Single

Multiple

If multiple practitioners' provider updates are needed, please download the EHP Roster Template and attach it in the upload field. All roster fields are required.

EHP Roster Template (Excel)
(Roster template revised 02/04/2022)

New Provider Roster Upload

Choose File

Additional Files Needed: Copy of license, Copy of malpractice, Copy of NPI verification (if readily available)

Choose File

Update Requested By

First Name

Group TIN #

Last Name

Contact Email

Contact Phone Number

Date Requested

Comments

Specialist NPI #

Provider Name

First Name

Last Name

Tax ID #

Practitioner will be termed from all locations associated with this TIN.

Group/Facility Name

Date Term Effective

Provider Term Reason

Reason

Update Requested By

First Name

Last Name

Contact Email

Contact Phone Number

Date Requested

Comments

Disclaimer

If you are terming more than 15 providers, you can submit your changes by emailing the details to EHPprovidercontracts@primehealthcare.com

Specialist NPI #

Provider Name

First Name

Last Name

Tax ID #

Practitioner will be termed from all locations associated with this TIN.

Group/Facility Name

Date Term Effective

Provider Term Reason:

Reason

Add More

Specialist NPI #

Provider Name

First Name

Last Name

Tax ID #

Practitioner will be termed from all locations associated with this TIN.

Group/Facility Name

Date Term Effective

Provider Term Reason

Reason

Add more

Specialist NPI #

Provider Name

First Name

Last Name

Tax ID #

Practitioner will be termed from all locations associated with this TIN.

Group/Facility Name

Date Term Effective

Provider Term Reason:

Reason

Add more

Specialist NPI #

Provider Name

First Name

Last Name

Tax ID #

Practitioner will be termed from all locations associated with this TIN.

Group/Facility Name

Date Term Effective

Provider Term Reason:

Reason

Add more

Specialist NPI #

Provider Name

First Name

Last Name

Tax ID #

Practitioner will be termed from all locations associated with this TIN.

Group/Facility Name

Date Term Effective

Provider Term Reason:

Reason

Add more

Specialist NPI #

Provider Name

First Name

Last Name

Tax ID #

Practitioner will be termed from all locations associated with this TIN.

Group/Facility Name

Date Term Effective

Provider Term Reason:

Reason

Add more

Specialist NPI #

Provider Name

First Name

Last Name

Tax ID #

Practitioner will be termed from all locations associated with this TIN.

Group/Facility Name

Date Term Effective

Provider Term Reason:

Reason

Add more

Specialist NPI #

Provider Name

First Name

Last Name

Tax ID #

Practitioner will be termed from all locations associated with this TIN.

Group/Facility Name

Date Term Effective

Provider Term Reason:

Reason

Add more

Specialist NPI #

Provider Name

First Name

Last Name

Tax ID #

Practitioner will be termed from all locations associated with this TIN.

Group/Facility Name

Date Term Effective

Provider Term Reason:

Reason

Add more

Specialist NPI #

Provider Name

First Name

Last Name

Tax ID #

Practitioner will be termed from all locations associated with this TIN.

Group/Facility Name

Date Term Effective

Provider Term Reason:

Reason

Add more

Specialist NPI #

Provider Name

First Name

Last Name

Tax ID #

Practitioner will be termed from all locations associated with this TIN.

Group/Facility Name

Date Term Effective

Provider Term Reason:

Reason

Add more

Specialist NPI #

Provider Name

First Name

Last Name

Tax ID #

Practitioner will be termed from all locations associated with this TIN.

Group/Facility Name

Date Term Effective

Provider Term Reason:

Reason

Add more

Specialist NPI #

Provider Name

First Name

Last Name

Tax ID #

Practitioner will be termed from all locations associated with this TIN.

Group/Facility Name

Date Term Effective

Provider Term Reason:

Reason

Add more

Specialist NPI #

Provider Name

First Name

Last Name

Tax ID #

Practitioner will be termed from all locations associated with this TIN.

Group/Facility Name

Date Term Effective

Provider Term Reason:

Reason

Add more

Specialist NPI #

Provider Name

First Name

Last Name

Tax ID #

Practitioner will be termed from all locations associated with this TIN.

Group/Facility Name

Date Term Effective

Provider Term Reason:

Reason

Update Requested By

First Name

Last Name

Contact Email

Contact Phone Number

Date Requested

Comments

This form will send your message to EHP Contracting as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with EHP Contracting through email, you accept associated risks. EHP Contracting does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your protected health information (PHI), please send us a message through the Secure Member or Provider portal.